How To Score Clock Draw Test

Dement Neuropsychol. 2015 Apr-Jun; 9(two): 128–135.

Language: English | Portuguese

Specific algorithm method of scoring the Clock Drawing Examination applied in cognitively normal elderly

MÉTODO COM ALGORITMO ESPECÍFICO PARA PONTUAÇÃO Practice TESTE DO DESENHO DO RELÓGIO EM IDOSOS COGNITIVAMENTE NORMAIS

Liana Chaves Mendes-Santos

¹PhD, Department of Psychology, Pontifical Catholic Academy of Rio de Janeiro RJ, Brazil.

Daniel Mograbi

¹PhD, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ, Brazil.

²Department of Psychology, Establish of Psychiatry, King's College London, United kingdom of great britain and northern ireland.

Bárbara Spenciere

ⁱⁱⁱBsC, Section of Psychology, Pontifical Cosmic University of Rio de Janeiro RJ, Brazil.

Helenice Charchat-Fichman

¹PhD, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ, Brazil.

Received 2015 February 12; Accepted 2015 April 25.

Abstract

The Clock Drawing Exam (CDT) is an inexpensive, fast and hands administered measure out of cognitive function, especially in the elderly. This musical instrument is a popular clinical tool widely used in screening for cognitive disorders and dementia. The CDT tin can be practical in different ways and scoring procedures also vary.

Objective

The aims of this study were to analyze the functioning of elderly on the CDT and evaluate inter-rater reliability of the CDT scored by using a specific algorithm method adapted from Sunderland et al. (1989).

Methods

We analyzed the CDT of 100 cognitively normal elderly aged 60 years or older. The CDT ("free-drawn") and Mini-Mental State Examination (MMSE) were administered to all participants. Vi independent examiners scored the CDT of thirty participants to evaluate inter-rater reliability.

Results and Determination

A score of 5 on the proposed algorithm ("Numbers in reverse order or concentrated"), equivalent to 5 points on the original Sunderland scale, was the most frequent (53.v%). The CDT specific algorithm method used had high inter-rater reliability (p<0.01), and mean score ranged from v.06 to 5.96. The high frequency of an overall score of 5 points may suggest the need to create more nuanced evaluation criteria, which are sensitive to differences in levels of impairment in visuoconstructive and executive abilities during aging.

Keywords: Clock Drawing Test, inter-rater reliability, elderly, neuropsychology

Abstract

O Teste practise Desenho do Relógio (TDR) é uma barata due east rápida medida de função cognitiva, de fácil aplicação, especialmente em idosos. Este instrumento é uma ferramenta clínica muito conhecida, amplamente utilizada no rastreamento de transtornos cognitivos east demência. O TDR pode ser aplicado de diferentes formas e a sua pontuação também varia.

Objetivo

Os objetivos deste estudo foram analisar o desempenho dos idosos no TDR e avaliar a confiabilidade inter-examinadores do TDR pontuado por um método com algoritmo específico, adaptado a partir dos critérios estabelecidos por Sunderland et al. (1989).

Métodos

Analisamos o TDR de 100 idosos cognitivamente saudáveis com 60 anos de idade ou mais. O TDR ("desenho livre") due east o Mini-Exame exercise Estado Mental (MEEM) foram administrados em todos os participantes. Seis avaliadores independentes pontuaram 30 TDR para avaliar a confiabilidade inter-examinadores.

Resultados e Conclusão

A pontuação v do algoritmo proposto ("Os números em ordem inversa ou concentrados") equivalente a 5 pontos na escala original de Sunderland foi a mais frequente (53,5%). O método com algoritmo específico practice TDR utilizado teve alta confiabilidade entre avaliadores (p<0,01), e a média da pontuação variou entre 5,06 due east five,96. A alta frequência de five pontos na pontuação geral pode sugerir a necessidade da elaboração de critérios de avaliação mais sutis, que sejam sensíveis às diferenças entre indícios de comprometimento nas habilidades visuoconstrutivas e executivas durante o envelhecimento.

INTRODUCTION

The Clock Drawing Test (CDT) is a unproblematic and ecological neuropsychological instrument that covers a wide range of cognitive functions, including selective and sustained attention, auditory comprehension, verbal working memory, numerical knowledge, visual retentiveness and reconstruction, visuospatial abilities, on-demand motor execution (praxis) and executive function.^one Some studies take demonstrated the robust psychometric properties of the CDT.^two-4

The CDT has been used as a cognitive screening tool, peculiarly in the elderly population, to differentiate cognitively normal individuals from individuals with cognitive impairment and dementia.^v-7 This exam has the chapters to evaluate multi-domain impairments that may go undetected past other cognitive screening instruments, such as the Mini-Mental State Examination (MMSE).^two,viii The relative independence of verbal abilities^ix,10 makes it peculiarly useful in patients presenting marked verbal impairment or aphasia. In add-on, the CDT has besides shown strong associations with other cerebral measures, such as the Cambridge Cerebral Examination (CAMCOG),^6,11,12 justifying the inclusion of the CDT in several neuropsychological cerebral screening batteries.^1,10,12

Although there is great interest in CDT every bit a screening musical instrument, a wide diverseness of CDTs accept been adult, each relying on different systems of assistants and quantitative or qualitative error scoring, with no consensus on which organisation produces the most valid results.^3,v,13 The currently used methods are Shulman et al.,¹⁴ Sunderland et al.¹⁰ and Mendez et al.^1-iii,15 These unlike applications and systems of scoring are somewhat similar and highly correlated in some aspects, only their diagnostic accuracy, and the cognitive processes involved in their functioning are different.¹⁶

CDT functioning is associated with several encephalon regions, including the bilateral parietal lobes, right and left posterior and middle temporal lobes, right eye frontal gyrus, and the right occipital lobe.^16,17 These areas can besides be associated with a broad spectrum of pathologies. A number of studies accept shown the potential of the CDT for investigating cognitive performance in patients with schizophrenia, Alzheimer'south disease, Parkinson's disease, depression and other disorders.^nine,18,19

Previous studies accept investigated the test-retest reliability,^1,9 and determined inter-rater reliability, of the CDT.^6,10,20-24 These studies compared the different application systems and showed that the systems were well correlated, took little time and had high inter-rater reliability. On the other paw, CDT reliability has rarely been assessed in population-based studies, peculiarly in developing countries. Three studies determining inter-rater reliabilities of the CDT in elderly in Brazil were found: 1 scored the tests with Shulman'due south method,²⁰ while the others compared the accuracy of scales (Mendez, Shulman and Sunderland;^six Sunderland, Shulman, Manos & Wu and Wolf-Klein²⁴) and determined the inter-rater reliability of CDT performance. These investigations showed good inter-rater reliabilities.

Ane of the most used methods of CDT scoring is Sunderland et al.¹⁰ This method of scoring is well established in the literature^ten,25-27 and widely used in Brazil, being part of cognitive screening batteries for the elderly.^28,29

With the aim of providing a more detailed, specific and quantitative analysis of the unlike aspects of CDT cess, the nowadays report proposed an algorithm method for scoring the CDT adjusted from Sunderland et al.¹⁰ To this end, the performance of 100 elderly was analyzed using the new algorithm, and its inter-rater reliability was evaluated.

METHODS

Participants. The sample was part of a larger report involving 350 elderly from customs centers, known as "Casas de Convivência", belonging to the Rio de Janeiro municipal administration. One hundred elderly took part in this study (93 females and seven males). The inclusion criteria were:

[i] to be literate (a person who can read and write; mean=ix.8 years of education, SD=4.2),
[2] to be aged 60 years or older (hateful historic period=72.half-dozen years onetime, SD=five.9), and
[3] to exist cognitively healthy (MMSE mean score=25.iii, SD=3.4).

Cut-off scores for the MMSE were defined according to educational level. MMSE scores range from 0 to thirty, with higher scores indicating better cognitive function; the cut-off for cognitive damage was eighteen in individuals with fewer than four years of formal education and 24 for participants with more than than four years of education.^8,xxx Exclusion criteria were: to exist visually and/or hearing impaired or have uncorrected deficits, presence of endocrine and metabolic abnormalities, neurological and psychiatric disorders, or difficulty executing hand movements due to rheumatic diseases.

Before entry to the study all participants received an caption on the objectives of the inquiry, and signed an informed consent class. The Research Ideals Committee of the State University of Rio de Janeiro approved this study.

Materials and procedures. Subjects were first submitted to a standardized questionnaire, which collected information on sociodemographic variables (i.e., gender, historic period and education), on subjective memory impairment (i.e., "Do you feel like your memory has gotten worse?"), and on comorbidities. All participants then completed the aforementioned protocol of cognitive screening tests. The tests were applied in the following sequence (based on Nitrini et al.³¹):

[i] MMSE;^8,30
[2] Memory Test Figures;³¹
[3] Exact Fluency – Animals;^9,32
[four] CDT (described below);
[v] The Lawton Instrumental Activities of Daily Living^33,34 (for further details see Charchat-Fichman et al.³⁵). Besides the cerebral and functional evaluations, participants completed the Geriatric Depression Scale (GDS).³⁶

The CDT was applied to all participants in the spontaneous modality that uses a pencil and blank sheet of paper. The patients were asked to describe a clock without a model. Trained examiners issued a standardized instruction: "Depict a clock, put in all the numbers, and ready the easily to 2 hours and 45 minutes." There was no time limit.

Tabular array 1 shows the original CDT scoring scale by Sunderland et al.,^ten which forms the basis of the new algorithm (Table 2). Both Tables 1 and two present the correspondence of higher scores indicating better functioning. Examples of the CDT scoring calibration by Sunderland et al.^x are given in Figure 1. According to the new algorithm (Table 2), the examiner must first mark with an "X" all the items nowadays in the clock drawing. The list of items has increasing complication.

Table ane

The original Sunderland method for scoring the CDT.¹⁰

x-half dozen	Drawing of clock face up with circle and numbers is more often than not intact.
10	Hands are in correct position.
9	Slight errors in placement of easily.
eight	More noticeable errors in placement of hour and minute easily.
vii	Placement of hands is significantly off form.
half-dozen	Inappropriate utilize of clock easily (i.e., use of digital display or circumvoluted of numbers despite repeated instructions).
5-one	Drawing of a clock face with circle and numbers is not intact.
v	Crowding of numbers at one end of the clock or reversal of numbers. Hands may still be nowadays in some fashion.
iv	Further baloney of number sequence. Integrity of clock face is now gone (i.e., numbers missing or placed at exterior of the boundaries of the clock confront).
3	Numbers and clock face no longer manifestly connected in drawing. Hands are not nowadays.
2	Drawing reveals some show of instructions being received but only a vague representation of a clock.
1	Either no attempt or an uninterpretable endeavour is made.

Table 2

New algorithm method for CDT scoring based on the original criteria of Sunderland et al.^x

You should mark with an "X" all the items present in the clock fatigued
(a)	Presence of circumvolve.	(j)	Presence of hour hand.
(b)	Presence of 12 numbers.	(k)	Presence of minute hand.
(c)	Numbers entered in the internal limit of the clock.	(50)	Infinitesimal hand proportionally larger than the hr hand.
(d)	Number in the correct ascending order.	(m)	One of the easily betwixt 2 and 3.
(east)	Numbers in correct spatial position.	(northward)	One of the hands on exactly nine.
(f)	Can you describe a directly vertical line betwixt 12 and 6.	(o)	Wrong use of easily (digital or circling the numbers).
(k)	Tin can you describe a straight horizontal line between 3 and 9.	(p)	Some prove of having understood that it is a clock.
(h)	Numbers not concentrated in one part of the clock.	(q)	Did not attempt or did not represent a clock.
(i)	Presence of two pointers.
Follow the algorithm for the score, just consider these iii points initially
ane. If the item "o" is checked, the score is 6 points.
2. If the item "p" is checked, the score is 2 points.
3. If the item "q" is checked, the score is 1 point.
The score volition exist x-half-dozen if the clock and the numbers are drawn correctly
10	Correct time (no "X" in the items: "o", "p", "q").
9	Very mild disorder of hands (absence of "Ten" in at least one item: "fifty", "m" or "n").
8	Mild disorder of easily (absenteeism of "10" in at to the lowest degree two items: "l", "g", "n").
7	Astringent disorder of hands (absence of "X" in the items: "l", "m", "n").
6	Wrong utilise of hands (presence of "X" in item "o").
The score volition be 5-1 if the drawing of the clock and the numbers are incorrect
v	Numbers in reverse order or concentrated (no "X" in the items: "d" or "h").
4	Numbers missing and located outside the boundary of the clock (no "Ten" in items: "b" and "c").
iii	Absence of easily (no "Ten" in the items: "i", "j", "m").
two	Only some evidence of having understood that it is a clock (presence of "X" in item p).
ane	Not tried or did not represent a clock (presence of "Ten" item in q).

An external file that holds a picture, illustration, etc. Object name is dn-09-02-0128-g01.jpg

Examples of CDT score in accordance with the specific algorithm method based on Sunderland et al.¹⁰: 9, v and two (right to left), respectively.

Inter-rater reliability was assessed by comparing CDT scores from six independent examiners, who each scored the same thirty clocks from subjects sampled randomly.

RESULTS

A summary of the participants' sociodemographic characteristics, functioning on cognitive screening tests, as well equally cerebral function and depression scales is given in Table 3. Table 4 shows functioning on the CDT.

Tabular array 3

Participants' sociodemographic characteristics, and performance on cerebral screening tests, equally well equally cognitive part and depression scales.

Sociodemographic characteristics		Mean	SD^*	Minimum value	Maximum value
Age		72.6	5.9	60	84
Years of education		nine.8	iv.ii	3	24
Instruments and scales	MMSE (Retentiveness Figures Test)	25.2	3.iii	18	xxx
	• Incidental Memory	25.4	1.1	2	8
	• Immediate Retentiveness ane	7.9	1.3	iv	10
	• Firsthand Memory 2	8.6	ane.i	v	10
	• 5 Minutes - Delayed Retention	7.7	ane.five	4	x
	• Recognition	9.nine	0.three	viii	10
Verbal Fluency		15	iv.8	5	27
Lawton's Scale		20.1	1.iv	18	21
GDS		1.9	two.1	0	8

Table 4

Participants' performance on CDT: mean, median, standard deviation, minimum and maximum score.

Northward	Mean	Median	Standard departure	Minimum score	Maximum score
100	5.22	5	2.02	2	10

According to the histogram shown in Figure 2, regarding the performance of the elderly on the CDT, the frequency of score "5" was 53.5%, and scores "i" and "7" were non present in the electric current sample.

An external file that holds a picture, illustration, etc. Object name is dn-09-02-0128-g02.jpg

Histogram showing the frequency of CDT scores co-ordinate to the scoring arrangement developed by Sunderland et al.¹⁰.

Pearson's correlation was used to evaluate the relationship between schooling, age and MMSE with CDT scores. No significant correlation was found between schooling and CDT (r=0.014, p>0.05) or age and CDT (r=0.04, p>0.05), only a significant positive correlation was found between MMSE and CDT (r=0.22, p<0.05).

On the other manus, the investigation of inter-rater reliability of the CDT, scored by criteria based on Sunderland et al.,¹⁰ showed that the mean ranged from 5.06 to 5.96 (Tabular array 5).

Table 5

Hateful and SD of CDT scores rated by the half dozen examiners.

Examiners	Mean	SD
one	5.06	ii.24
ii	five.66	ii.57
3	5.96	2.74
4	5.73	2.55
5	5.23	1.95
6	v.6	ii.71

Pearson's correlation analysis was performed between the scores found by the six independent raters for 30 tests. A significant positive correlation was found between the examiners (p<0.01): one and 2 (r=0.79), 1 and 3 (r=0.7); one and iv (r=0.75); ane and 5 (r=0.84), i and 6 (r=0.71), 2 and 3 (r=0.87), 2 and 4 (r=0.79), ii and 5 (r= 0.79), 2 and 6 (r=0.79), 3 and iv (r=0.79), iii and 5 (r=0.69), 3 and six (r=0.eight), 4 and 5 (r=0.79), four and six (r=0.88) and 5 and 6 (r=0.74).

The understanding between raters was high, consistently remaining statistically significantly above expected take chances agreement (in all cases, p<0.001). The combined kappa for all six examiners was 0.sixty, with pairwise analyses between evaluators indicating an average level of agreement of 90.2% and an average weighted kappa of 0.69.

DISCUSSION

The current study analysed the performance of a cognitively normal elderly community sample on the CDT using a specific algorithm score method based on the Sunderland et al.^x organisation. The mean score of participants was 5.22, and the standard deviation 2.02. The score v ("Numbers in reverse club or concentrated") was observed in 53.5% of clock drawings.

In general, studies with the CDT compare the functioning of patients and controls in different applications and scoring systems^2,25,37 or verify the clinical validity of the test,^21,23,38 or investigate the translation and adaptation of the CDT model for a particular population.^39,xl At that place are few studies in community-dwelling house samples or cognitively normal elderly.^22,41-43

V Brazilian studies using Sunderland's scoring method institute higher scores than the present study (5.22, and standard divergence 2.02). Two of these studies did not mention CDT scores,^6,24 while the other results were: 9.7 (±1.07),⁴¹ 7.8 (±ii.2),²⁸ and 9.1 (±one.8).¹¹ Withal, comparison of the current findings with results of these studies is hampered because of a number of differences in study design. The most important difference was related to the intrinsic characteristics of the sample. The cited studies used small-scale clinical samples recruited in hospital settings, in contrast to the present study which used a large sample of normal elderly from community centers with heterogeneous age and educational levels.^{6,11,24,28,31,41} The objectives of the studies too varied. Some compared different methods of CDT scoring,^24,41 others compared the instrument with other tests and finally in that location was a report that evaluated the profile of the elderly subjects on the CDT²⁸ based on a selected group of normal elderly as a control group compared to Alzheimer'southward disease patients.

Studies in the international literature that used the same method as Sunderland to score the CDT plant the following results: 7.5 (±1.ix),²⁵ 8.4 (±1.6),²⁷ 8.7 (±1.1),¹⁰ and 8.9 (±ane.4).²⁶ Similar to the Brazilian studies, all of these found higher scores for normal elderly individuals^10,26,27 than in the present study, except Kirby et al.²⁵ who institute lower scores compared to the other international studies. Some studies failed to mention all important data, for example, the educational level^10,26 or did not use formal cognitive testing for normal controls¹⁰ (including the MMSE^ten,27) while another did not divide the clinical group when describing the sample characteristics,²⁷ hindering comparisons among the studies. The aim of the nowadays study differs from the main objective of the previous studies in that its aim was to evaluate the performance of the elderly with and without cognitive impairment.^10,25-27

An important consequence regarding the functioning of the elderly is the high percentage (53.five%) of the sample with scores of "5". The criterion for a score of "5" in Sunderland's original method is "Crowding of numbers at ane end of the clock or reversal of numbers. Clock Easily may still be nowadays in some fashion" and in the new algorithm denoted: "Numbers in reverse lodge or concentrated". The lower mean scores on the CDT compared to other studies, and the loftier frequency of elderly that scored at this level could exist explained by the fact that strict correction was used to score the CDT in this written report. Sunderland's method in its original version had a more than subjective arroyo, for case, very high CDT scores, even with numbers slightly full-bodied, could be found in Sunderland et al.¹⁰ (Figure 1, p. 727). According to Sunderland'due south method, particular 5 should be scored just when there is a drastic concentration, and in the present research this item included people with slight and astringent difficulty in planning. Thus, when strict criteria are used, unlike results are obtained compared to the literature.

In this sense, information technology would be necessary to develop more than specific scoring criteria that may be sensitive to planning strategy and visual-constructive execution of the CDT, and which could better differentiate specifically those elderly with possible executive dysfunction. Other methods of scoring the CDT, including semi-quantitative and qualitative scoring systems, attempt to discriminate the level of executive planning in clock drawings,^42,44,45 and emphasize the evaluation of executive components in CDT.^42-44 For instance, Royall et al.⁴⁵ developed the Executive Clock Drawing Chore (CLOX) in order to discriminate these components and let a more specific analysis of how the executive functions tin exist tested in the CDT.

No significant correlation was plant betwixt education or aging and CDT scores. The relationship betwixt education, aging and CDT functioning is controversial in the literature.^{22,24,38,41,43} This finding may also exist related to the existence of diverse application methods and different scoring scales. For example, Brodaty and Moore found a correlation of CDT score with years of instruction for the Shulman and Sunderland, but not for the Wolf-Klein scoring system.ⁱⁱ Sunderland et al.¹⁰ did not study the educational level of control subjects in the original written report.

On the other hand, a significant positive correlation was found between the CDT and MMSE, confirming previous findings.^6,7,15 A loftier correlation has been found for the scales of Shulman,¹⁴ Mendez¹ and the CLOX scale.⁴⁵ The association betwixt MMSE score and several CDTs was also high in the study by Schramm et al.^vii

These various systems of application and scoring are an obstruction to establishing direct comparisons and drawing conclusions. The different forms of awarding include differences in the clock time requested (ii:45, 11:x, viii:05) and presence of drawing aid (due east.g. some have a pre-drawn circle). In addition, the various scoring systems include: 10 hierarchical patterns (0-10), scale based on errors each scored 0/i (0-twenty), clock divided into eighths, points given for numbers and hands in correct place (0-x) and others.^{3,fourteen,37,43}

In this study, an algorithm with more specific scores based on Sunderland et al.^x criteria was devised to increase inter-rater reliability. The test of the inter-rater reliability showed that the criteria developed for the present report were reliable and a significant positive correlation was found between the six independent examiners. These results are similar to those establish in previous studies, also indicating high inter-rater reliability of CDT scores.^10,21-23 Over again, the diverse ways of presenting the test and the different principles involved in scoring, make comparisons hard. Another aspect that hampers comparisons is the employ of several dissimilar report designs. Some studies examined inter-rater reliabilities of the CDT scored past one scoring system in cognitively normal elderly²⁰ or in differentiating between cognitively normal and individuals with different types of pathologies,² while others examined inter-rater reliability using different scoring systems among cognitively normal elderly^22,37 or cognitively normal and individuals with different types of diseases.²¹ Ii other studies that evaluated the inter-rater reliability using various score systems, including the method of Sunderland et al.,^x compared subjects with and without pathologies (fibromyalgia and mild cognitive harm, MCI)^37,46 and showed good inter-rater reliability.

The idea of systematic scoring of the CDT has focused on the development and standardization of simple and piece of cake-to-translate scoring methods.^21,22 There are two general CDT scoring approaches, including qualitative and quantitative approaches. The Sunderland et al.^x is a semi-quantitative scoring system that focuses on scoring the whole clock.³⁷ Other quantitative scoring systems focus on different aspects of the clocks (such as clock face, numbers or hands) and score them separately (i.e., the Clock Drawing Interpretation Calibration by Mendez et al.¹ and Rouleau et al.¹²). Furthermore, the scoring systems differ regarding scoring procedures.

1 limitation of this written report is the not-stratification of participants past age for comparison. Perhaps the advanced age of some participants may have influenced the low boilerplate scores. Some other question to be considered centers on the intrinsic characteristics of the sample and on the volunteers that participated in the activities of the Casas de Convivência. For instance, the sample comprises mostly women (93%), with few wellness atmospheric condition. However, considering this is a convenience sample, information technology was not possible to limit recruitment on the basis of personal characteristics In addition, other Brazilian studies also feature a higher pct of women,^11,xx,24,41 making it unlikely that this represents a major bias in results. These subjects were normal elderly (criterion for inclusion in the sample was to score above the cut-off point on the MMSE), but some older adults with MCI might have been included in the sample; a number of conditions associated with aging could be present, and some comorbidities not directly related with cognition may have influenced the results. Another limitation to exist considered is associated with the method of sample selection. To adequately address choice bias, a randomized sample would have been better than the convenience sample used in the present study. Moreover, other limitations were the absence of other measures of executive functions to compare with the CDT and no functional literacy exam.

The present findings represent an important contribution to the discussion on which CDT administration and scoring organization produces the virtually valid results. The results confirmed the consistency of the scoring criteria of Sunderland et al.^ten. Furthermore, the findings contribute to the give-and-take most the lack of consensus on the different scoring criteria developed for the CDT and on which would produce more than valid results. On the other hand, they may farther advise the demand for creating more than subtle evaluation criteria, which are sensitive to the differences between impairment in visuoconstructive and executive abilities during aging.

Future research should replicate these findings in elderly with college and lower formal educational activity to compare the touch on of educational level on the CDT. Additional studies could explore more than qualitative aspects of the CDT, including strategies implemented, as well equally comparison it to other scoring criteria, and clinical validation in the case of Alzheimer's disease, MCI and depression.

Acknowledgement

Christina Martins Borges Lima, Ana Lara Soares Blum Malak, Amanda Buhler Riccieri, Marina Zaitune Baumgratz Lopes Bueno, Maria Fernanda Fernandes de Castro Barbosa, Eduarda Naidel Barboza e Barbosa.

Footnotes

This study was conducted at the Department of Psychology, Pontifical Catholic Academy of Rio de Janeiro, Brazil.

Disclosure: The authors report no conflicts of involvement.

Contributed past

Writer contributions. Liana Chaves Mendes-Santos wrote the paper and participated in statistical assay. Daniel Mograbi participated in statistical analysis and revised the paper. Bárbara Spenciere wrote the newspaper. Helenice Charchat-Fichman designed the written report, wrote the paper, participated in statistical analysis and revised the paper.

Grant Support. CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), FAPERJ (Fundação Carlos Chagas Filho de Amparo à Pesquisa do Rio de Janeiro).

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